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When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
- A. When did your symptoms first begin?
- B. Can you describe the pain and how it feels?
- C. Do you have any changes in vision?
- D. Have you experienced any seizures?
Correct Answer: D
Rationale: The correct answer is D: Have you experienced any seizures? This question is crucial because seizures can be a common symptom of a brain tumor. By asking about seizures, the nurse can gather important information about the client's condition and potential complications. Seizures can also indicate the location and size of the tumor.
A: When did your symptoms first begin? This question is important, but seizures are more specific to brain tumor assessment.
B: Can you describe the pain and how it feels? Pain can vary and may not always be present with a brain tumor.
C: Do you have any changes in vision? Vision changes can occur but may not be as indicative of a brain tumor as seizures.
In summary, asking about seizures is crucial for immediate assessment and management of a client with a brain tumor, as it can provide valuable insight into the client's condition.
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While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?
- A. Elevate the head of the client's bed
- B. Auscultate the client's breath sounds
- C. Measure the length of the apneic periods
- D. Suction the client's oropharynx
Correct Answer: C
Rationale: The correct answer is C: Measure the length of the apneic periods. This action is crucial in assessing the severity of Cheyne-Stokes respirations and guiding further interventions. By measuring the length of apneic periods, the nurse can determine the duration of respiratory pauses and their impact on oxygenation. This information helps in deciding the appropriate treatment, such as administering supplemental oxygen or notifying the healthcare provider. Elevating the head of the bed (choice A) can help with breathing but does not address the root cause. Auscultating breath sounds (choice B) is important but does not directly address the apneic periods. Suctioning the oropharynx (choice D) is not indicated unless there is an airway obstruction.
The nurse is planning care for a client receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?
- A. Administer an antiemetic before meals
- B. Provide frequent mouth care
- C. Encourage small, frequent meals
- D. Offer clear liquids
Correct Answer: A
Rationale: The correct answer is A: Administer an antiemetic before meals. Administering an antiemetic before meals helps prevent and manage nausea associated with chemotherapy by blocking receptors that trigger nausea and vomiting. This intervention targets the root cause of the symptom. Providing frequent mouth care (B) may help with taste changes but does not directly address nausea. Encouraging small, frequent meals (C) and offering clear liquids (D) may be helpful for some clients, but they do not specifically target nausea caused by chemotherapy.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute by nasal cannula. The client develops respiratory distress and the nurse increases the oxygen to 4 liters per minute. Shortly afterward, the client becomes lethargic and confused. What action should the nurse take first?
- A. Reposition the nasal cannula
- B. Lower the oxygen rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct Answer: B
Rationale: The correct answer is B: Lower the oxygen rate. Increasing oxygen flow too quickly can lead to oxygen toxicity in COPD patients, causing symptoms like lethargy and confusion. Lowering the oxygen rate will help alleviate the symptoms and prevent further harm. Repositioning the nasal cannula (choice A) is not the priority in this situation. Encouraging coughing and deep breathing (choice C) may not address the immediate issue of oxygen toxicity. Monitoring oxygen saturation (choice D) is important but should follow lowering the oxygen rate to address the current symptoms.
A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?
- A. Weight gain of 2 pounds in 24 hours
- B. Presence of a cough
- C. Edema in the lower extremities
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. This assessment finding is crucial in a client with CHF and fluid volume overload as it indicates potential worsening of heart failure leading to pulmonary congestion. Shortness of breath is a common symptom of fluid accumulation in the lungs, requiring immediate intervention to prevent respiratory distress.
A: Weight gain of 2 pounds in 24 hours may indicate fluid retention but is not as urgent as shortness of breath.
B: Presence of a cough can be a symptom of CHF but is not as specific or concerning as shortness of breath.
C: Edema in the lower extremities is also a common finding in CHF but does not directly signify acute respiratory compromise as shortness of breath does.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?
- A. Increase the oxygen flow rate
- B. Instruct the client to breathe deeply and cough
- C. Check the client's oxygen saturation level
- D. Place the client in a high-Fowler's position
Correct Answer: C
Rationale: The correct answer is C: Check the client's oxygen saturation level. This is the first action the nurse should take to assess the effectiveness of the current oxygen therapy and determine the client's oxygenation status. A: Increasing the oxygen flow rate without assessing the client's oxygen saturation level may lead to potential oxygen toxicity. B: Instructing the client to breathe deeply and cough may not address the underlying issue of hypoxemia. D: Placing the client in a high-Fowler's position may help with breathing but does not address the immediate concern of the client's difficulty breathing. Checking the oxygen saturation level provides crucial information for appropriate interventions.